General
1. Although the first factory for their production
opened in 1856, it was not until World War I that cigarettes accounted
for over half of British tobacco sales. Cigarette consumption
"increased rapidly" during the conflict, their "convenience
in the trenches" and inclusion in soldiers' rations doing
much to extend their popularity.[6]
Even at that time, according to Mr Martin Broughton, Chairman
of British American Tobacco, there was some knowledge of the health
risks involved, as indicated by the use of the term "coffin
nails" for cigarettes.[7]
The First World War has, in the popular imagination, become associated
with the wasteful loss of life on a huge scale. Indeed some 12%
of all those recruited to fight for the allied forces who served
on the western front lost their lives.[8]
Ultimately, however, tobacco was to prove a far more prolific
killer. It is now understood that tobacco kills 50% of those who
use it over a lifetime and half of those before the age of 70.[9]
2. Almost any report on the health risks of smoking
begins with a mass of statistics because the statistics in themselves
point to the profound impact of tobacco on public health. Some
120,000 people are killed by tobacco each year in Britain alone,
according to official figures.[10]
The Royal College of Physicians describes cigarette smoking as
"the single largest avoidable cause of premature death and
disability in Britain" and "the greatest challenge and
opportunity for all involved in improving the public health".[11]
In the European Union, 15% of all deaths are attributed to smoking,
that figure rising to 24% in respect of deaths in middle age (35-69
years).[12]
The World Health Organization estimates that tobacco kills one
in ten adults worldwide, costing at least four million lives in
1998. As the tobacco epidemic continues its progression from developed
to less developed countries it estimates that this proportion
will increase to one in six of all deaths, or ten million deaths
each year by 2030. On present trends, of the children alive today
in the world, 250 million will be killed by tobacco.[13]
3. In concluding his recent Green College Lecture,
Sir Richard Doll, one of the pioneers in the field of epidemiology
relating to tobacco use, remarked:
"That so many diseases
- major and minor- should be related to smoking is one of the
most astonishing findings of medical research in this century;
less astonishing perhaps than the fact that so many people have
ignored it."[14]
In an appendix to his lecture, Sir Richard lists
those diseases "caused in part by smoking":[15]
CANCERS CAUSED IN PART BY SMOKING
| Cancer of: |
|
| Lip | Myeloid Leukaemia
|
| Nose | Stomach
|
| *Lung | Kidney Pelvis
|
| *Larynx | Kidney Body
|
| *Mouth | Bladder
|
| *Pharynx | Pancreas
|
| *Oesophagus | Liver
|
*Risk increased five or more times
VASCULAR DISEASES CAUSED IN PART BY SMOKING
| Ischaemic heart disease
| *Aortic Aneurysm |
| Myocardial degeneration
| *Peripheral Vascular Disease
|
| Hypertension (fatal) |
*Buerger's Disease |
| Arteriosclerosis | *Pulmonary Heart Disease
|
| Subarachnoid Haemorrhage
| |
| Cerebral Thrombosis |
|
| Cerebral Haemorrhage |
|
*Risk increased five or more times
RESPIRATORY DISEASES CAUSED IN PART BY SMOKING
| *Chronic Obstructive Lung Disease
|
| Pneumonia |
| Asthma |
| Pulmonary Tuberculosis |
*Risk increased five or more times
OTHER DISEASES CAUSED IN PART BY SMOKING
| Gastric Ulcer | Periodontitis
|
| Duodenal Ulcer | *Tobacco Amblyopia
|
| Crohn's Disease | Age related macular degeneration
|
| Osteoporosis | Cataract
|
| Reduced Fecundity | Reduced growth of foetus
|
*Risk increased five or more times
He also lists those few conditions in which smoking
has apparent health benefits:
DISEASES INVERSELY ASSOCIATED WITH SMOKING
| Parkinson's Disease |
Cancer of body of uterus |
| Ulcerative Colitis |
Fibroids |
| Aphthous Ulcers | Nausea and vomiting of pregnancy
|
| Allergic Alveolitis |
Pre-eclampsia |
| ?Alzheimer's Disease[16]
| |
A more detailed analysis of the extent to which smoking
contributes to death comes in the latest report from the Royal
College of Physicians:[17]
Estimated number and percentage of deaths
attributable to smoking by cause, UK 1997.
| | Deaths from disease estimated to be caused by smoking
|
| | Number
| As % of all deaths from disease
|
| Diseases caused in part by smoking:Cancer
| Men
| Women
| Total
| Men
| Women
| Total
|
| Lung | 19,600
| 9,600 |
29,200 |
89 | 75
| 84 |
| Upper respiratory |
1,500 | 400
| 1,900 |
74 | 50
| 66 |
| Oesophagus | 2,900
| 1,700 |
4,600 | 71
| 65 |
68 |
| Bladder | 1,600
| 300 |
1,900 | 47
| 19 |
37 |
| Kidney | 700
| 100 |
800 | 40
| 6 |
27 |
| Stomach | 1,600
| 300 |
1,900 | 35
| 11 |
26 |
| Pancreas | 600
| 900 |
1,500 | 20
| 26 |
23 |
| Unspecified site |
2,400 | 600
| 3,000 |
33 | 7
| 20 |
| Myeloid leukaemia
| 200 |
100 | 300
| 19 |
11 | 15
|
| Respiratory |
|
| |
| |
|
| Chronic obstructive lung disease
| 14,000
| 9,700 |
23,700 |
86 | 81
| 84 |
| Pneumonia | 5,600
| 4,800 |
10,500 |
23 | 13
| 17 |
| Circulatory |
|
| |
| |
|
| Ischaemic heart disease
| 16,800
| 7,500 |
24,300 |
22 | 12
| 17 |
| Cerebrovascular disease
| 3,000 |
3,800 | 6,900
| 12 |
9 | 10
|
| Aortic aneurysm |
3,800 | 2,000
| 5,800 |
61 | 52
| 57 |
| Myocardial degeneration
| 200 |
300 | 500
| 22 |
12 | 15
|
| Atheroscelerosis | 100
| 100 |
200 | 15
| 7 |
10 |
| Digestive |
| |
| |
| |
| Ulcer of stomach or duodenum
| 900 |
1,000 | 2,000
| 45 |
45 | 45
|
| Total caused by smoking
| 75,600
| 43,200
| 118,800
| |
| |
| Diseases prevented in part by smoking
| |
| |
| |
|
| Parkinson's disease
| 900 |
400 | 1,300
| 55 |
28 | 43
|
| Endometrial cancer
| - |
100 | 100
| - |
17 | 17
|
| Total prevented by smoking
| 900
| 500
| 1,400
| |
| |
| Deaths from all causes due to smoking
| |
| |
| |
|
| (Caused less prevented)
| 74,700
| 42,700
| 117,400
| |
| |
| Totals may not add up due to rounding to nearest 100.
|
4. The pattern of smoking diseases varies considerably
between, and sometimes even within, countries. Until recently
most epidemiological studies concentrated on Western countries,
but studies are now emerging from lower-income countries such
as India and China. The recent World Bank report Curbing the
Epidemic noted that deaths in China from ischaemic heart disease
make up a far smaller proportion of deaths caused by tobacco than
in the West; in China, respiratory diseases and cancers account
for most deaths while for a "significant minority" the
cause of death is tuberculosis.[18]
Whilst lung cancer is an important hazard, a major study of the
health effects of tobacco in China found "a tenfold variation
from one Chinese city to another".[19]
Nevertheless, despite these differences, the outcomes are much
the same. As the World Bank concluded "it appears that the
overall proportion who are eventually killed by persistent
cigarette smoking is generally about one in two in many populations".[20]
5. The Health Committee has not examined directly
the health risks of smoking in its previous inquiries. We have,
however, issued two reports relating to the role of advertising
in relation to cigarette consumption. In the previous Parliament
we concluded "in the face of the evidence that has now been
accumulated, the Government can no longer maintain its position
that a further tightening of tobacco advertising controls is unlikely
to contribute to a reduction of the prevalence of smoking in the
UK".[21]
Then in our First Report of the current Parliament we expressed
our concern at the Government's proposal to seek an EC directive
which contained an exemption for Formula One from the proposed
advertising ban.[22]
6. During the course of this inquiry we have often
drawn attention to the fact that it was as long ago as 1954 that
a health minister, Iain Macleod, disclosed in a written Answer
to the House of Commons that it was "established that there
is a relationship between smoking and cancer of the lung".[23]
The ambivalence of governments towards the consequences of moving
from an acknowledgment of the dangers of smoking to taking action
to curb it is well summed up in Iain Macleod's later recollection
that he "earned the plaudits of the Treasury, a lot of news
coverage, and a headache by chain-smoking my way through my press
conference announcing the first 'conclusive' findings of the causal
link".[24]
7. It seemed astonishing to us that, almost 50 years
after Government recognized the dangers inherent in smoking, tobacco
products remained on sale in a remarkably unregulated fashion.
In July 1999 we announced our intention to conduct an inquiry
into "The Tobacco Industry and the Health Risks of Smoking".
Our terms of reference were as follows:
"The Committee will
examine what action the tobacco industry has taken, and is currently
taking, in response to the scientific knowledge of the harmful
effects of smoking and the addictive nature of nicotine. It will
also assess the role of Government in providing consumer protection."[25]
8. Between November 1999 and February 2000 we took
oral evidence from Department of Health (DoH) officials, the Chief
Medical Officer (CMO), the Health Education Authority, Action
on Smoking and Health (ASH),[26]
Leigh, Day and Co. Solicitors, the World Health Organisation (WHO),
the Royal College of Physicians (RCP), the British Medical Association
(BMA), British American Tobacco (BAT), Gallaher Group Plc, Imperial
Tobacco Group Plc, Philip Morris Europe S.A., R J Reynolds Tobacco
(UK) Limited (RJR), Freedom Organisation for the Right to Smoke
(FOREST),[27]
the Tobacco Manufacturers' Association (TMA), four advertising
agencies (M&C Saatchi, CDP, Mustoe Merriman Herring &
Levy, and TBWA GCT Simons Palmer Ltd), Mr Bernie Ecclestone, (Chairman,
Formula One Management Limited), Mr Max Mosley (President, Fédération
Internationale de l'Automobile (FIA)), the Rt Hon Kenneth Clarke
MP (Deputy Chairman, BAT), the journalist Mr Duncan Campbell,
Ms Yvette Cooper, MP, Parliamentary Under-Secretary of State,
Minister for Public Health, and the Rt Hon Alan Milburn, MP, Secretary
of State, Department of Health.
9. In the course of this inquiry we have also received
over 100 written memoranda. We are grateful to all those who have
submitted written and oral evidence.
10. In November-December 1999 we undertook a visit
to the USA as part of our inquiry. Recent activity in the USA
has radically altered the climate of discussion over the impact
of tobacco on public health. In August 1994 the State of Minnesota
and Blue Cross and Blue Shield of Minnesota filed a complaint
against the tobacco industry in the USA. The resulting trial led
to the release of over 30 million pages of internal documents
from the tobacco companies. On 16 November 1998 a $206 billion
(over 25 years) settlement between the principal US tobacco companies
and 46 states that had sued to recoup the costs of treating people
with smoking-related diseases was announced. Separate deals had
already been agreed with Mississippi ($3.36 billion over 25 years),
Florida ($11 billion over an indefinite period), Texas ($15.32
billion over 25 years) and Minnesota ($5.6 billion over 25 years).[28]
11. In order to obtain a fuller picture of developments
in the USA we met The Food & Drug Administration (FDA), Clifford
Douglas of Tobacco Control Law & Policy Consulting, Star Tobacco,
the National Smokers Alliance, the National Cancer Policy Board,
Smoke Free Maryland, members of the Maryland Senate, members of
the Maryland House of Delegates, Dr Benjamin, Secretary of Health
and Mental Hygiene in the state of Maryland, Donna Jacobs, Governor's
Deputy Chief, Maryland, the Governor of Maryland, the Campaign
for Tobacco Free Kids, Mr Michael Pertschuk of the Advocacy Institute,
Philip Morris Associates, the Federal Trade Commission, the Centre
for Disease Control and Prevention and the National Cancer Institute.
12. Since much of the regulation which applies to
tobacco products emanates from Brussels we also visited the European
Commission in Brussels for discussions with the Health Commissioner
and officials. Within the UK we visited the Centre for Tobacco
Control Research at the Centre for Social Marketing, University
of Strathclyde, the Tyne and Wear Health Action Zone, BAT's Research
and Development Facility at Southampton and the same company's
document depository at Guildford. We are grateful to all those
who facilitated these visits.
13. We should also like to record our gratitude to
our Specialist Advisors, Professor Gerard Hastings of the Centre
for Tobacco Control Research at the Centre for Social Marketing
at the University of Strathclyde, Professor Martin Jarvis of the
Health Behaviour Unit, Department of Epidemiology and Public Health,
University College, London and Professor Sir Richard Peto of the
Nuffield Department of Clinical Medicine at the University of
Oxford. In an inquiry in which much of the evidence has been of
a tendentious nature they have guided us most expertly and, in
our view, with complete objectivity.
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